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Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.
Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Jt Comm J Qual Patient Saf. 2019;45:249–258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.